Healthcare Provider Details

I. General information

NPI: 1063022598
Provider Name (Legal Business Name): ALEX THANH THACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 BRIGHTON AVE STE 100
ALLSTON MA
02134-2301
US

IV. Provider business mailing address

50 BROCK ST APT 1
BRIGHTON MA
02135-2795
US

V. Phone/Fax

Practice location:
  • Phone: 617-402-5444
  • Fax:
Mailing address:
  • Phone: 617-402-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLABA10001944
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: